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Neurology 3A > Strokes + Bleeds > Flashcards

Strokes + Bleeds Flashcards

1
Q

TIA definition

A

Transient (resolve within 24hrs) episodes of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

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2
Q

Dysphasia

A

Difficulty in speaking, understanding, reading and writing.

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3
Q

Dysarthria

A

Impairment in motor ability to speak.

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4
Q

Risk of recurrent stoke at 1yr and 5yrs

A
  1. 1% in 1 year

26. 4% in 5 years

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5
Q

Risk of a stoke at 1 week and 1 month after a TIA

A

1 week = 8%

1 month = 12%

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6
Q

Differential diagnosis of a stroke or TIA

A 
Hypoglycemia
Drug or alcohol toxicity
Syncope, vertigo, dizziness
Seizure
Aura and migraine (<1hr)
Trauma to CNS
Infection - Meningitis, encephalitis or CNS abscess
Wernicke's encephalopathy
SOL - Tumour or subdural haematoma
Dementia
Delirium
Vasculitis
Ramsay-Hunt Syndrome
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7
Q

Risk factors for a ischaemic stroke/TIA

A 
Modifiable = smoking, alcohol misuse, physical inactivity, hypertension, poor diet.
Non-modifiable = sickle cell disease, DM, antiphospholipid syndrome (and other hypercoaguable disorders), AF, male.
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8
Q

Complications of a stroke

A

Seizure, cerebral oedema, pulmonary embolism and thrombus disease, ataxia, hemiparesis, hemiplegia, falls, incontinence, pain, depression, fatigue, dysphagia, dysphasia, dysarthria, pressure ulcers.

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9
Q

2 types of stroke

A

Ischaemic - 85%, vascular occlusion or stenosis from atherosclerosis (bifurcation of Circle of Willis), carotid or cardiac embolism.
Hemorrhagic - 15%. blood collection from vascular bleed. Intracranial or subarachnoid.

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10
Q

Investigating to conduct in ?stroke/TIA

A

CT or MRI of brain, however, only 75% are visual on CT.
Bloods - FBC, U+E, Clotting screen, ESR and CRP, TSH, Blood sugars, Fasting lipid
ECG, echocardiogram
Chest x-ray
Carotid Doppler for internal carotid artery stenosis
Cerebral angiography

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11
Q

Prevention of stroke and TIA (secondary prevention)

NON PHARMACOLOGICAL

A
  • Minimise time spent sedentary, exercise plans to encourage physical activity.
  • Smoking cessation
  • Encourage 5 a day, reduce salt intake, reduce saturated fat intake, 2 portions of oily fish a week.
  • Limit alcohol intake to 14units/week
  • Optimise medications (contraception advise!)
  • Annual winter flu vaccinations
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12
Q

Driving after a stroke

A
  • After stroke or high-risk TIA = no driving for 1 month.
  • It is the patient’s responsibility to tell DVLA, however, they only need to inform them if they are sill unfit to drive after this 1 month period.
  • Bus, coach or head goods vehicle drivers must tell DVLA about any stroke or TIA irrespective of 1 month period.
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13
Q

Pharmacological prevention of stroke and TIA

A

Antiplatelets e.g. Clopidogrel, aspirin.
Lipid modification drugs e.g. statin
Monitor BP and offer anti-HTN is appropriate.
Anticoagulant e.g. adjusted-dose warfarin.

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14
Q

Management of a TIA

A

1) 300mg Aspirin
2) Specialist assessment within 24hrs at TIA clinic.
3) Secondary prevention with drugs and lifestyle advice (dipyridamole, clopidogrel, aspirin, statin).
4) Brain imaging considered on assessment e.g. possible carotid endarterectomy patients.

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15
Q

Management of an acute ischaemic stroke

A

1) Admission to specialist acute stroke unit.
2) ABCD resuscitation including assess swallowing (NG tube) and BM check (aim for BM 4-11mmol/L).
3) Brain imaging with head CT +/- contrast angiography.
4) Choose appropriate treatment once haemorrhage stroke has been excluded. 300mg aspirin, thrombloysis + thrombectomy for ischaemic stroke etc.
5) MDT care.
6) Early mobilisation
7) Rehabilitation, secondary prevention (lifestyle + drugs) and care plan.

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16
Q

Thrombolysis

A

Reduces death and need for care/dependency.

Inclusion criteria:
Seen within 4.5hrs of symptom onset
Over 18yrs
Hemorrhagic stroke excluded.

Contra-indications: recent birth, major surgery or trauma, history of intracranial haemorrhage, active malignancy, arteriovenous malformation, INR >1.7, seizures present, BP >185/110, severe liver disease or portal HTN.

Drugs: IV recombinant tissue plasminogen activator/alteplase.

Followup CT after 24hrs

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17
Q

Stroke rehabilitation

A 
Make individualised rehab plan
Physiotherapy to improve mobility.
Orthoptics
Podiatry
Dietitians
Occupational therapist
SALT
Manage complications such as disorientation, incontinence, poor swallowing, nutrition.
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18
Q

ABCD2 risk assessment

A

stroke risk after a TIA.
A = age >60
B = BP >140/90
C = clinical features unilateral weakness or speech distrubance
D = duration >1hr or 10-59mins
D = diabetes
Score of 6 or more strongly predicts a stroke, score of 4 or more needs specialist assessment within 24hrs.

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19
Q

Types of haemorrhage

A

Subarachnoid, Subdrual and epidural

20
Q

Causes of a stroke

A

Hyper-viscosity - sick cell disease
Microemboli - AF
Thromboemboli - carotid stenosis
Vasculitis

21
Q

Subarachnoid haemorrhage, causes, CFx, Ix and Mx.

A
  • Spontaneous bleed into intracranial space.
  • Rupture of Berry aneurysm which lie in junctions or bifurcations of circle of Willis, AVM.
  • Sudden acute headache, photophobia, collapse, vomiting, seizures, coma.
  • Neck stiffness, Kernig’s sign - can’t straighten leg due to pain in hamstring when hip flexed at 90 degrees.
  • FBC, clotting profile, BM, ECG. CT = star shaped lesion. LP if CT normal = CSF bloody then xanthochromic yellow due to breakdown of blood.
  • Refer to specialist unit and neurosurgery ASAP.
  • Nimodipine/CCB, stable BP and hydration, surgical clipping or endovascular coiling,
22
Q

Subdural haemorrhage; causes, RFx, CFx, Ix and Mx.

A
  • Rupture of bridging cortical veins between brain and dura. Haematoma forms between arachnoid and dura maters.
  • Elderly and alcoholics at risk.
  • Can be trivial trauma, 9 months ago.
  • Fluctuating headache and consciousness, drowsy, confused, unsteady gait. intellectual slowing, unsteady.
  • Signs of raised ICP (fundoscopy!)
  • CT = crescent-shaped haematoma and midline shift.
  • Irrigation or evacuation via a burr twist or burr hole craniostomy.
23
Q

Epidural haemorrhage; causes, CFx, Ix and Mx.

A
  • Middle meningeal artery laceration from trauma (near eye)
  • Temporal or parietal bone trauma or dural venous sinus tear.
  • Lucid interval of recovery followed by decline. Initial no LOC but may be drowsy then period of fine then decline with headache, n+v, confusion, fits, limb weakness, ipsilateral pupil dilation, coma.
  • CT- Biconvex haematoma. DO NOT LP. Skull x-ray for fracture.
  • Clot evacuation and ligation of bleeding vessel.
24
Q

Primary intracerebal haemorrhage causes, S+S, Ix.

A
  • Thrombolysis, Charcot-Bouchard aneurysm rupture, trauma.
  • Sudden onset headache, LOC.
  • CT = lobar haematoma.
25
Q

Common causes of cerebral venous thrombosis

A 
Oral contraceptives
Dehydration
Intracranial malignancy
Recent lumbar puncture
Hyperthyroidism
HF
Crohn's or UC
Antiphospholipid syndrome
Cerbral abscess
Meningitis
Infliximab
Most commonly in sagittal sinus and transverse sinus.
26
Q

Todd’s paresis

A

Post ictal weakness. example of focal near signs after a seizure.

27
Q

Features which make a TIA presentation high risk and management.

A

ABCD2 score greater than 4
Crescendo TIA = more than 1 in previous week.
New arrhythmia
Known carotid stenosis.
Rx = 300mg aspirin daily for 2 weeks then clopidogrel, specialist assessment within 24hrs.

28
Q

Contra-indications for thrombolysis

A 
IC bleed or history of.
Onset of symptoms voer 4.5hrs or unclear.
Seizures at onset.
Low platelets.
BP over 185 systolic or 110 diastolic.
Major trauma or surgery in past 3months.
Recent childbirth
AVM or aneurysm
On anticoagulant meds or have high INR.
29
Q

Symptoms and arteries in a Total Anterior Circulation Stroke

A

Both middle and anterior cerebral arteries affected.
All of:
•Homonymous hemianopia
•Unilateral weakness or sensory loss in face, arms, legs.
•Higher cerebral dysfunction e.g. dysphasia

30
Q

Symptoms and arteries in Partial Anterior Circulation Stroke

A

Middle or anterior cerebral arteries.
2 out of:
•Homonymous hemianopia
•Unilateral weakness or sensory loss in face, arms, legs.
•Higher cerebral dysfunction e.g. dysphasia

31
Q

Weakness or sensory loss in an anterior artery partial anterior circulation stroke

A

In foot and leg

32
Q

Weakness or sensory loss in an middle artery partial anterior circulation stroke

A

Face and hands

33
Q

Arteries in the posterior circulation

A

Vertebrobasilar

34
Q

Symptoms in a brainstem posterior circulation stroke

A

Cranial nerve palsy
Isolated homonymous hemianopia
Horizontal gaze palsy
Drowsyness

35
Q

Other name for complete infarction at the pons in a posterior circulation stroke

A

Locked-in syndrome

36
Q

Symptoms and area of brain affected in a PICA stroke of posterior circulation stroke
What does PICA stand for?

A

Posterior Inferior Cerebellar Artery.
Cerebellum.
Ataxia, nystagmus, vertigo.
LATERAL MEDULLARY SYNDROME

37
Q

Stroke symptoms in a young adult who has been involved in RTA

A

Carotid artery dissection.

38
Q

Some focal neurologies seen in TIAs

A 
Unilateral weakness
Unilateral sensory loss
Ataxia
Syncope
Amaurosis fugax
Homonymous hemianopia
Cranial nerve palsy
39
Q

Acute vestibular circulation stroke

A

Vertigo, dizziness, nystgmus, nausea + vomiting, head motion intolerance, unsteady gait.

40
Q

Who gets a head CT

A

?stroke =

  • indications for thrombolysis or thrombectomy
  • on anticoagulant treatment
  • known bleeding tendency e.g. antiphospholipid
  • GCS below 13
  • fluctuating or progression or symptoms
  • signs of raised ICP (papilloedema, neck stiffness).
  • signs of SAH e.g. severe headache.

For head injury from trauma =

  • GCS <13 on initial assessment
  • GCS <15 after 2hrs of injury
  • suspected open depressed skull fracture
  • basal skull fracture signs (battle sign)
  • seisre
  • focal neuro deficit
  • 1 episode of vomiting.
41
Q

Long term management after an acute ischaemic stroke

A
  • 300mg aspirin daily for 2 weeks post event.
  • Clopidogrel (life-long)
  • Assess cause (24hr ECG for AF, lipid levels, BP).
  • Use Barthel Index to assess dependent in activities of daily living post stroke.
  • Stroke rehabilitation from MDT (SALT, psych, physio etc etc).
42
Q

Why CCB in SAH?

A

Prevent vasospasm and subsequent ischaemic brain injury

43
Q

Mechanism of action of alteplase

A

Plasminogen activator leading to lysis of fibrin

44
Q

Name 3 conditions which predispose you to SAH

A

Polycystic kidney disease
Ehlers-Danlos syndrome
Neurofibromatosis type 1

45
Q

How to assess patients ADLs/independence post-stroke?

A

Barthel Index

Neurology 3A (7 decks)

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